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Semper Fi Service Dog Training Program Application

   

1. Name*________________________________________________________________________ 

2. Address*______________________________________________________________________

3. The Semper Fi Service Dog training location is in Mission Bay. You must be able to travel there once a week for 26 consecutive weeks. 

4. Street Address ________________________________________________________________________

5. Address Line 2 _________________________________________________________________________

6. City State ZIP Code_______________________________________________________________

7. Preferred Contact Phone Number*__________________________________________________

8. Applicant's Email*______________________________________________________________________

9. Cell Phone*____________________________________________________________________

10. Home Phone____________________________________________________________________

Emergency Contact:

11. Name*________________________________________________________________________

12. Relationship*___________________________________________________________________

13. Phone*________________________________________________________________________

14. Email ________________________________________

15. Please describe how you heard about Heal Our Troops America Semper Fi Service Dog Training Program?* _____________________________________________________________________

16. Occupation*____________________________________________________________________

17. Marital Status*__________________________________________________________________

18. Spouse's Name (if applicable) ______________________________________________________

19. Are you currently a defendant in an ongoing criminal court case?* Yes / No

20. Have you ever been convicted of a felony?* Yes / No

To help us identify candidates who fit the mission of this program please be advised that a background check may be run on the day of the first interview.

21. Wars/Conflicts in Which You've Fought*______________________________________________

22. Branch of Armed Service*

Select all that apply.

   

23. Army

• Marines

• Air Force

• Navy

• Coast Guard

   

24. Current Status of Service*

   

• Active Duty

• Reserve

• Retired

•   Veteran

  

25. Type of Discharge*

A "General- Under Honorable Conditions" discharge is not the same as an "HONORABLE" discharge. Due to the criteria of our program, each applicant must have an "HONORABLE" Discharge from the United States Armed Forces to be eligible for enrollment.

• Honorable

• General - Under Honorable Conditions

• General - Under Other Than Honorable Conditions

• Dishonorable

• Rank*

26. Can You Provide Proof of Military Service?* Must have DD214 Yes / No

27. Can You Provide Proof of "Disability by the Veterans Administration"?* Yes / No

28. Also, must provide letter from Physician/Counselor or VA stating you are medically, mentally and physically able to handle the responsibilities of owning a dog. Yes / No

29. What Would You Like a Service Dog to be Able to Help You With?*

_____________________________________________________________________________

30. Do You Live Alone?* Yes / No

31. Are There Children in the Home?* Yes / No

You need to ask yourself the following questions. If you cannot answer "YES" to all of the following questions, a Service Dog might not be the answer for you.

32. Do you feel capable of responding to the challenges of having a PTSD SERVICE DOG in public places where you might be questioned as to your service dog's certification and legal right to be present?* Yes / No

33. Are you financially able to take on the costs of caring for a dog for 10-15 years?* Yes / No

34. Are you prepared to care or arrange for care of a dog every single day?* Yes / No

35. Are you willing and able to accept the training and socialization obligations accompanying a Service Dog?* Yes / No

36. Do you agree not to take the dog into areas that could be hazardous to the health of the dog?* Yes / No

37. Are you prepared to attend weekly training classes required by the trainer until your dog is deemed ready as a service dog?* Yes / No

Canine Availability:

38. Do You Need a Dog Purchased for You to be Your Service Animal?* Yes / No

You must understand and agree to the following Terms of Use to be eligible to participate in the Semper Fi Service Dog Training Program.

39. I understand if I do not attend my assigned classes with my dog (with the exception of injury or illness), I will be removed from the program. If the dog was donated to me by Heal Our Troops America, it may be returned to the program as well. INITIALS:

40. I understand that not every dog will turn out to be a service dog even after many weeks of training. If the dog does not do well with the training or temperament issues begin to arise, the dog will not be able to continue with the program. INITIALS:

41. I understand that a background check will be done to ensure no charges of domestic violence or animal abuse have been filed. INITIALS:

42. If the Service Animal candidate or it’s associated veteran is removed from the program for any reason, all training equipment as well as the dog will be returned to the program to be used by a different Service Animal team. INITIALS:

43. Enrollment and Documentation*

44. I understand that enrollment cannot be completed until I have provided all of the required documentation. INITIALS:

45. USE OF IMAGES CONSENT Optional: I give my permission to Semper Fi Service Dog to use my picture for their website, Facebook and other program advertisements. * Yes / No